Annotate one qualitative research article from a peer-reviewed journal on a topic of your interest.Provide the r

Annotate one qualitative research article from a peer-reviewed journal on a topic of your interest.Provide the reference list entry for this article in APA Style followed by a three-paragraph annotation that includes:A summaryAn analysisAn application as illustrated in this example

Evans et al. International Journal of Behavioral Nutrition and
Physical Activity 2015, 12(Suppl 1):S5
Open Access
Increasing access to healthful foods: a qualitative
study with residents of low-income communities
Alexandra Evans1*, Karen Banks2, Rose Jennings1, Eileen Nehme1, Cori Nemec1, Shreela Sharma1, Aliya Hussaini3,
Amy Yaroch4
Background: Inadequate access to healthful foods has been identified as a significant barrier to healthful dietary
behaviors among individuals who live in low-income communities. The purpose of this study was to gather lowincome community members’ opinions about their food purchasing choices and their perceptions of the most
effective ways to increase access to healthful foods in their communities.
Methods: Spanish and English focus groups were conducted in low-income, ethnically-diverse communities.
Participants were asked about their knowledge, factors influencing their food purchasing decisions, and their
perceptions regarding solutions to increase access to healthful foods.
Results: A total of 148 people participated in 13 focus groups. The majority of participants were female and
ethnically diverse (63% Hispanic, 17% African American, 16% Caucasian, and 4% “other”). More than 75% of the
participants reported making less than $1999 USD per month. Participants reported high levels of knowledge and
preference for healthful foods. The most important barriers influencing healthful shopping behaviors included high
price of healthful food, inadequate geographical access to healthful food, poor quality of available healthful food,
and lack of overall quality of the proximate retail stores. Suggested solutions to inadequate access included
placement of new chain supermarkets in their communities. Strategies implemented in convenience stores were
not seen as effective. Farmers’ markets, with specific stipulations, and community gardens were regarded as
beneficial supplementary solutions.
Conclusion: The results from the focus groups provide important input from a needs assessment perspective from
the community, identify gaps in access, and offer potential effective solutions to provide direction for the future.
In 2012, food insecurity—or lack of consistent access to
enough nutritious food to meet the needs of all household members because of insufficient money or other
resources for food—was experienced by approximately
17.6 million households in the United States (U.S.) [1].
Food insecurity places individuals at greater risk for
engaging in less healthful dietary behaviors and consuming fewer servings of fruits and vegetables (F&V), dairy
foods, and complex micronutrients compared to individuals who are food secure [2,3]. A strong relationship
between food insecurity and poverty exists, with higher
* Correspondence:
Michael & Susan Dell Center for Healthy Living, The University of Texas
School of Public Health Austin Regional Campus, Austin, TX, USA
Full list of author information is available at the end of the article
rates of food insecurity and hunger occurring among
individuals of lower socioeconomic status (SES) [2].
Food access is a critical component of food insecurity,
and it is often considered a function of a variety of factors,
including the spatial proximity to food resources, as well
as the affordability, cultural appropriateness, and the nutritional adequacy of available resources. Limited food access
has been found to disproportionately affect low-income
individuals who are more likely to live in communities
with limited availability of healthful foods, specifically
fresh fruits and vegetables [1,4-10]. These types of underserved communities, often referred to as “food deserts”
[5], tend to have few food retailers who sell healthful food
products (e.g., fresh F&V) and more food retailers who sell
less healthful foods [11-13]. Low-income individuals living
in communities with limited healthful food access tend to
have less healthful diets and run a higher risk for chronic
© 2015 Evans et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited. The Creative Commons Public Domain Dedication waiver (
zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Evans et al. International Journal of Behavioral Nutrition and
Physical Activity 2015, 12(Suppl 1):S5
disease, such as various cancers, cardiovascular disease,
and Type 2 diabetes, compared to individuals living in
higher income communities [8,13-15].
According to data provided by the United States
Department of Agriculture (USDA), 23.5 million people
(approximately 20%) in the U.S. live in low-income
communities more than 1 mile from a supermarket.
Additional data show that people living in low-income
areas with limited access spend significantly more time
(19.5 min) traveling to a supermarket compared to the
national average (15 min) [16]. As a result of the relatively high prevalence of U.S. households living in communities with limited access and the noted health
disparities among those living in these type of communities, federal and local initiatives are underway to
increase both geographic and economic access to more
healthful foods. Current strategies include increasing
geographic access by increasing points of healthful food
access [17-20]. Although there has been an emphasis on
placing more chain supermarkets in food deserts [9],
other geographic strategies to improve the healthfulness
of the community food environment include changing
the inventory of convenience stores (i.e., small retail
stores which typically sell a limited variety of staple groceries and snacks), increasing the number of farmers’
markets and farm stands, and establishing community
gardens [18,19]. In addition to efforts to increase geographic access to more healthful foods, strategies to
increase economic access are also being implemented.
These types of strategies include pricing schemes (i.e.,
decreasing price of more healthful foods and/or increasing price of less healthful foods) at supermarkets, convenience stores, and at farmers’ markets (e.g., Double
Dollar or Double Up Food Bucks Program incentives
which provides consumers with incentives that match
the value of their federal nutrition benefits when used to
purchase fresh, local produce at participating farm-toretail venues) [21].
Both geographic and economic strategies are being
implemented in communities all across the U.S. with relatively little evidence that they are effective and with almost
no input from community stakeholders regarding the feasibility and cultural appropriateness of these strategies.
The purpose of this paper is to present in-depth qualitative data obtained from focus groups with residents living
in underserved, low-income communities about their food
purchasing choices and their perceptions of the most
effective ways to increase access to more healthful foods in
their own communities. The results from the focus groups
will provide important input to help inform lay communities as well as identify gaps to help provide direction for
future intervention efforts. Although we located two focus
groups studies conducted in food deserts in Great Britain
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[22,23], this study is unique because, to the best of the
authors’ knowledge, no other studies in the United States
have explored these issues in a qualitative, comprehensive
For this study, qualitative data regarding access to more
healthful foods (defined in this study as F&V) were collected from 148 adults living in low-income food desert
areas in central Texas in spring 2011. Specifically, focus
group participants were asked about their knowledge of
healthful eating, factors influencing their food purchasing
decisions, and their perceptions regarding solutions to
increase access to more healthful foods. Institutional
Review Board approvals from The University of Texas at
Austin and The University of Texas Health Science Center
were obtained before commencement of the study.
Focus group participants were recruited from 11 geographically proximate zip codes, with high concentrations of
individuals living in households below the poverty
threshold and with limited access to healthy food, as
defined by the lack of a chain supermarket in the community within one mile from the majority of residents
[24]. Figure 1 illustrates the study area and the location
of chain supermarkets within that area. Of the 11 zip
codes in the study area, five lacked a supermarket, with
the nearest grocery store between 3 and 15 miles away.
Table 1 compares demographic information from the
study area from which focus group participants were
recruited to demographics from Texas and the U.S.
In order to recruit a random sample of community
residents, over 20 community leaders, including church
pastors, social service providers, non-profit directors, and
neighborhood association members, were contacted to
help determine venues and times for the focus groups.
Flyers were distributed to schools, churches, community
recreation centers, select businesses, and door-to-door.
Inclusion criteria for participation were: 1) resident of
one of the 11 zip codes included in our study, 2) responsibility for purchase of most household food, and 3) ages
18-65 years. While this study explicitly focused on the
needs of low-income residents, specific income level was
not a requirement for participation. However, given that
the communities were all considered low income, it was
assumed that most of the participants would be low
income and exposed to a low-income community environment. Interested and eligible individuals were asked to
contact the research team or attend a scheduled focus
group meeting. For participating in the focus groups,
participants were given a small bag of local farm-fresh
produce worth approximately $20 USD.
Evans et al. International Journal of Behavioral Nutrition and
Physical Activity 2015, 12(Suppl 1):S5
Page 3 of 12
Figure 1 Food stores in study area
Focus group
The focus group sessions were interactive discussions
guided by 15 open-ended questions using a standardized
focus group protocol that lasted approximately one hour
[25]. The questions were developed using the U.S.
Department of Agriculture (USDA) concept of food
security as a guiding framework. The USDA defines food
security as access by all people at all times to enough
nutritious food for an active, healthy life and encompasses both geographic and economic access to healthy
food [1]. Questions were developed to specifically examine participants’ perceptions with regard to what constitutes a more healthful diet, factors influencing foodpurchasing decisions, and how to increase geographic
and economic access to healthful food in the participants’
communities. Three examples of questions included in
this study were: 1) How often do you normally purchase
food? 2) What are some reasons that limit the amount of
fresh fruits and vegetables you buy? 3) What would help
increase your consumption of fresh fruits and vegetables?
Each question had specific prompts that were used when
necessary. The questions focused on three specific venues
where residents are able to obtain food: supermarkets,
convenience stores, and farmers’ markets. These venues
were chosen because they provide, in theory, equal access
to all community members living in a specific community. During the focus groups, participants also mentioned community and school gardens, thus these points
of access will also be discussed in this paper. The focus
group scripts were developed in English, then translated
into Spanish, and then back translated into English by a
native-Spanish speaker.
Data collection
A total of 13 focus groups (7= Spanish; 6=English) were
conducted (n=148) by trained moderators with experience in conducting both English and Spanish focus
groups. In addition to the regular moderator, an assistant
moderator was used for each focus group as well. Spanish
focus groups were conducted either by a trained, fluent
Spanish speaker or by a trained English speaker accompanied by a bilingual translator. Before the start of each
session, research staff obtained written informed consent
from all participants. All study materials were available in
Evans et al. International Journal of Behavioral Nutrition and
Physical Activity 2015, 12(Suppl 1):S5
Page 4 of 12
Table 1. Comparison of specific demographic variables at
study, state and national level
Median Age
% White
% Black or African American
% Hispanic
% Asian
40,146 50,920
% Unemployed
Median Income
% Enrolled in SNAP in the Past 12
% Individuals Below Poverty Level3
% High School Graduates
% Spanish Speaking Household
% Living in Same House a Year Ago
Source: U.S. Census Bureau, 2010 Census
Source: U.S. Census Bureau, 2008-2012 American Community Survey
Poverty is determined when the total household income of the
householder’s family falls below the appropriate poverty threshold
(determined by: size of family, number of related children, and, for 1- and
2-person families, age of householder).
Average percentage graduation rates of all 11 zip codes represented by
study participants.
both English and Spanish. At the start of the focus groups,
participants completed a short socio-demographic (e.g.,
race/ethnicity, sex, age, participant employment, and food
security status) and specific food behaviors survey (e.g.,
frequency of food preparation, frequency of dinner eaten
at home). The socio-demographic questions were drawn
from an earlier study conducted with a very similar population [26]. The sessions lasted approximately 45-60 minutes and all sessions were audio taped. Upon completion
of the focus groups, trained research assistants transcribed
the audiotapes. Spanish focus groups were transcribed in
Spanish, checked for accuracy against original recordings,
translated into English by a native Spanish speaker, and
back-translated into Spanish for quality control.
Data analysis
In order to describe the sample, frequencies for specific
variables on the quantitative questionnaire were calculated. For the qualitative data analysis, a thematic content
analysis approach was used. Each transcript was entered
into the qualitative software package QSR NVivo (version
8, 2008, QSR International Pty Ltd, Cambridge, MA).
Two independent coders experienced in the analysis of
qualitative data reviewed the interviews and decided on a
coding scheme based on the focus group questions and
the recurrent themes found in the transcripts. In addition, a set of decision rules to standardize the coding procedure was created. The two coders then went back
through all the transcripts and assigned specific codes to
each segment of text that corresponded to each index
code and corresponding subcategories. Organization of
coded and sub-coded passages of the transcribed text
was examined and differences in coding were resolved
through consensus by the two coders. Emergent themes
were identified through frequency of coding within similar contexts and across focus groups. All index codes that
were mentioned less than three times were not included
in further analyses. [25].
Results and discussion
A total of 148 people participated in 13 focus groups.
The majority of participants were female and the total
sample was ethnically diverse: 63% Hispanic, 17% African
American, 16% Caucasian, and 4% “other.” Among Hispanic participants, the majority (54%) reported speaking
Spanish most of the time. Approximately three-fourths of
participants (72%) reported making less than $1999 USD
per month and 68% reported sometimes or almost always
“running out of food by the end of the month.” (See
Table 2).
According to the Center for Public Priorities, a family
of four with two adults needs to earn a gross monthly
income between $4198 USD to afford to “get by” in Central Texas [27]. Based on this estimate, only about 12%
percent of the focus group participants earned enough to
afford to live comfortably in Central Texas. However,
only 30% of the participants received SNAP benefits and
only 21% received Women, Infants, and Children (WIC)
benefits, which may be one reason 68% of the participants reported sometimes or almost always feeling food
insecure. These numbers suggest that strategies that
increase economic access to food are important for this
Summary of qualitative results
The following themes were derived from the data:
1) High level of knowledge about healthy eating, 2) Factors influencing food purchasing decisions include: cost
of food (economic access), distance to retail store (geographic access), quality of food and quality of retail
stores, 3) Suggested ways to improve physical access to
healthful foods through supermarkets, convenience
stores, farmers’ markets and community gardens, 4)
Suggested way to increase economic access to healthful
Knowledge of healthful eating
A review of psychosocial factors associated with fruit
and vegetables intake among adults showed knowledge
as a significant predictor of F&V consumption across an
array of socio-demographic populations [28]. In our
study, focus group participants were very knowledgeable
Evans et al. International Journal of Behavioral Nutrition and
Physical Activity 2015, 12(Suppl 1):S5
Page 5 of 12
Table 2. Description of focus group participants (n = 148)
Black or African American
Hispanic or Latino
Language spoken at home
I don’t know
Separated or divorced
Single, never married
Marital Status
Highest Level of Education
Less than 12 years
High school graduate/GED
Some college
College graduate
Total Household Income/Month
$0 – 999 USD
$1000 – 1999
$2000 – 2999
$3000 – 3999
$4000 +
Receive WIC vouchers
Almost always
Not very often
Receive Supplemental Nutrition Assistance Benefits (SNAP)
Run out of food before end of month because can’t afford to buy more
of what it means to eat healthy. The majority of the participants used consumption of fruits and vegetables (F&V)
as a proxy when answering questions about healthy foods
in general. Participants unanimously agreed that a variety
of F&V is an essential part of a more healthful diet. They
listed F&V as more healthful because—in their opinion—
these foods provide vitamins, nourishment, strength, help
lower cholesterol, cause one to think clearly, and prevent
diet-related diseases. On participant noted that F&V
“help your body balance and process everything properly.” The words “fresh,” “organic,” “seasonal” and “local”
were all mentioned in connection to F&V and health, in
that respective order of frequency. Results from other
studies concur with our findings that levels of knowledge
about healthy foods among low-income shoppers tends
to be high [29], suggesting that lack of knowledge is not
Evans et al. International Journal of Behavioral Nutrition and
Physical Activity 2015, 12(Suppl 1):S5
the driving factor influencing food purchasing and dietary behaviors among this population [26,30,31].
Factors influencing food purchasing decisions
Despite the high level of knowledge about the components of a healthy diet, participants voiced several external barriers to consuming more healthful foods. The
four most common influences reported included high
cost of healthful foods, inadequate geographical access
to healthful food, poor quality of available healthful
food, and lack of overall quality of the proximate retail
stores. Focus group participants identified high cost as
the number one factor affecting food choice: “We always
look for what’s more economical.” For families with limited financial resources, the need to stay within a fixed
budget caused a trade-off between more healthful foods
and, oftentimes, less healthy but calorie-dense foods,
such as meat. As one participant reported: “I look at the
asparagus and I realize that I can buy a big rib eye for
the same price so I get the rib eye.” F&V were viewed as
very healthy but not as satiating as other foods, posing a
dilemma for families who were forced to choose
between their health values and meeting their basic
caloric needs. The price of food and budget restrictions
also limited families’ options in the variety of foods purchased and ways food was prepared. Participants
reported “rarely” or “not regularly” shopping with a prepared grocery list, rather shopping for the same products every week or “looking for special sales” because
the cost of the food and preparation methods were
known and the amount of food wasted was limited.
Similar results were found in another focus group study
with residents of food deserts. In this study, younger
mothers with children cited financial constraints as
greatly influencing their food purchasing decisions [22].
Although cost of food was the dominating factor
affecting food-purchasing decisions, the distance to a
supermarket or large grocery store that carried higher
quality products was also a major concern for participants. In some cases, residents reported having to travel
up to 20 miles to buy groceries. Particularly for participants who did not own a car, transportation to supermarkets was a hardship and potentially very expensive
as some participants reported taking a taxi to the store
due to poor and uncoordinated public transportation.
Even participants who did own a car cited high gasoline
prices as a barrier to driving to supermarkets outside
their community. As one participant noted, “I always
look for the closest place because I can save gas and
sometimes there are things that are cheaper at certain
places, and we know they are on sale, but also if the
store is too far you have to have in mind the traffic, the
time and the gas, so I prefer to buy the food in the one
that is closest whether it’s more expensive or not.” For
Page 6 of 12
many of the families in the study, grocery shopping is
not a solitary errand. It requires forethought to incorporate this activity into one’s daily commute or combine
with other errands in order to save gas money and
requires advanced preparation (e.g., placing a cooler full
of ice in the car so food does not spoil).
Quality of both the available foods and the retail
stores were also consistent factors mentioned as important influences on food purchasing decisions. Terms like
fresh, not mildewed, not wilted, not bruised, not rotten,
good appearance, good shape, and pretty were used to
describe food of high quality. High quality stores were
described as having a nice physical condition, clean,
good upkeep, not too much traffic or panhandling in the
parking lot. Many participants who did live near a
supermarket or grocery store mentioned that the quality
of foods, especially produce and prepared foods, at the
local supermarkets and grocery stores was greatly inferior compared to food items sold at other supermarkets
across town in higher-income neighborhoods on the
west side of town (Figure 1). In fact, some participants
stated that when they had the opportunity, they would
try to go to a store much further away because the quality of foods found at those stores was better. However,
among other participants this was rare, since it was hard
to justify a trip to a better store with the high price of
gas “because if it’s too expensive, it’s not convenient for
you to go too far because you’ll spend more [on gas] than
what you have.” Thus, even though these individuals
had relatively easy geographic access to a supermarket,
they did not have access to quality food. This underscores the need to not only provide geographic and economic access, but also access to quality products.
In summary, results from the focus groups confirmed
that both economic and geographic access are major factors influencing how low-income individuals shop for
their food. The four specific factors that influence how
and where food purchases are made include: price of
food, geographic access, quality of food for sale, and quality of store. Other studies have found similar results and
underscore the importance of the affordability, variety,
and quality of food as well as proximity to grocery stores
as main influences on where to shop [31-36].
Increasing geographic access to healthful foods
When asked how access to healthful foods could be
improved, responses depended somewhat on the geographic location of where participants lived. However, all
focus group conversations included comments about
supermarkets, convenience stores, and alternative venues
such as farmers’ markets and community gardens.
Participants living in areas with no supermarket consistently stated that the solution to increase access to more
Evans et al. International Journal of Behavioral Nutrition and
Physical Activity 2015, 12(Suppl 1):S5
healthful foods was to build a conveniently located
supermarket offering a wide variety of quality items in a
convenient location. For those participants already living
close to a supermarket, solutions focused on increasing
the quality of food available in the store and on improving the overall quality of the store. Some participants
also mentioned expanding services provided by stores
and have stores create common spaces for community
classes on how to grow food and hosting regular farmers’
Participants specifically preferred supermarkets over
smaller-sized grocery stores because supermarkets
offered a variety of other needed services (e.g., payment
of bills, etc.). One participant shared her thoughts about
a supermarket: “Whenever you go to [the store], you can
also pay your bills; it’s faster, you can use other services
there. That way, I only go to one place and at the same
time I get my groceries like the fruits, the tuna, the nopales
[cactus], everything is there, ready!” For some participants, a larger size meant variety: “I like the big [store]
because it’s got everything in there. I mean you could just
go in there and have a field day. You can shop!” This
result was also found in a focus group conducted in an
area of Great Britain considered to be a food desert [22].
Given that the most commonly cited barriers to the purchase of more healthful foods by participants were cost,
lack of geographic access, and lack of quality produce,
introducing new supermarkets in communities would
seem to be a logical solution. However, past studies indicate that the simple placement of a new supermarket in a
food desert or similar type of community does not necessarily translate into an increase of healthier food purchasing or healthier food intake [37-41]. Only two studies have
found significant positive results after a new grocery store
was introduced into a community [37,41]. The results
from one study show that among participants with “very
poor” diets at pre-intervention, F&V consumption
increased from 4.13 portions to 9.83 portions per week,
and among participants with “poor” diets, 60% increased
F&V consumption [37]. It is important to note that while
each of the studies examined the impact of a new supermarket, there is a lack of consistency across each of the
studies. For example, while the new supermarket evaluated
by Sadler et al. (2013) increased geographic access, the
authors imply that food prices were relatively higher at
this independent grocer compared to other available alternatives; thus, in this low-income community, economic
access was not improved by the new store [38]. One reason for the mixed results may be that supermarkets
increase availability of both healthful and unhealthful
foods, which may translate into more purchases of both
healthful and unhealthful foods [42].
On the other hand, results from studies assessing the
impact of intervention strategies placed within an
Page 7 of 12
already existing supermarket, including increasing availability of healthful foods and making healthful foods
more affordable, tend to be positive. A review of 58 articles published from the late 1940s to July 2012 evaluating the impact of interventions implemented in
supermarkets to promote healthful food choices and eating practices found that the combination of pricing,
increasing availability of healthful foods, points-ofpurchase signage, and advertising is an effective strategy
to increase the purchase of more healthful food items
[43]. A recent study by Waterlander et al. (2013) also
found that a 50% discount on fresh F&V throughout a
six-month period in supermarkets resulted in a significant increase in F&V purchases and consumption [44].
At a three month follow-up, after price discounts had
ceased, the impact on F&V purchasing and consumption
had ceased as well, suggesting that price adjustments
must be maintained to maintain purchasing behaviors,
especially since F&V tend to be more price elastic than
other foods [45].
In summary, evidence from the literature suggests that
increasing geographic access by simply placing supermarkets in food deserts may not increase the purchase and
consumption of healthful foods. However, altering costs
of foods and increasing availability of healthful foods in
already-existing stores does seem to positively impact
consumers’ purchasing and consumption behaviors.
Given that placing a grocery store in a low-income area
can be a lengthy and complicated process (e.g., lengthy
approval procedures from city government) and is not
always an economically practical option for retailers [46],
improving the quality of already-existing grocery stores,
if available, may be a more viable option. If no supermarket or grocery store is already available, then introducing
a new supermarket that offers competitive prices and a
variety of affordable, high quality foods will increase
access and potentially will increase more healthful dietary
behaviors, including increased F&V consumption.
Convenience stores
When participants were specifically asked about their use
of convenience stores for food purchasing, the overall
sentiment was very negative. Convenience stores were
typically perceived to be too expensive, as reflected by a
participant who stated, “…I’d prefer to grab my car and
go to Store A (local chain retail store) instead. It’s more
economical.” Another participant felt that convenient
stores “conveniently make that price ridiculous.” Convenience stores also were perceived as having limited and
very low-quality food products, especially produce. One
participant was put out by having to go to corner stores
since there weren’t enough large grocery stores nearby,
noting “most of them have processed foods.” Participants
reported a general feeling of frustration and mistrust
towards convenience store businesses. One participant
Evans et al. International Journal of Behavioral Nutrition and
Physical Activity 2015, 12(Suppl 1):S5
expressed, “My thing is that I don’t [shop at] the convenience store, even though I’m wasting 5 or 6 bucks worth of
gas not going in, I’m still not going to give him $5 or $6 for
a pack of bacon. I can’t do it. I would rather spend the $5
or $6 on gas and go to [store B]. Them knowing there is no
access to this type of stuff so they mark the food up real
high. That’s not cool.”
Transformation of convenience stores to sell healthier
foods has been posited as an alternative or interim solution to the introduction of chain supermarkets. Gittelsohn
et al. (2012) published a review of 16 original articles
examining the impact of strategies to increase access to
more healthful foods in convenience stores [47]. The most